Niccolò Nocchi

Minimally invasive surgery for benign intradural extramedullary spinal meningiomas: experience of a single institution in a cohort of elderly patients and review of the literature.

Meningiomas of the spine are the most common benign intradural extramedullary lesions and account for 25%–46% of all spinal cord tumors in adults. The goal of treatment is complete surgical resection while preserving spinal stability. Usually, these lesions occur in the thoracic region and in middle-aged women. Clinical presentation is usually nonspecific and the symptoms could precede the diagnosis by several months to years, especially in older people, in whom associated age-related diseases can mask the tumor for a long time. We report a series of 30 patients, aged 70 years or more, harboring intradural extramedullary spinal meningiomas. No subjects had major contraindications to surgery. A minimally invasive approach ( hemilaminectomy and preservation of the outer dural layer) was used to remove the tumor, while preserving spinal stability and improving the watertight dural closure. We retrospectively compared the outcomes in these patients with those in a control group subjected to laminectomy or laminotomy with different dural management. In our experience, the minimally invasive approach allows the same chances of complete tumor removal, while providing a better postoperative course than in a control group.

Endoscopic endonasal approach for the treatment of a large clival giant cell tumor complicated by an intraoperative internal carotid artery rupture

Giant cell tumors (GCTs) are primary bone neoplasms that rarely involve the skull base. These lesions are usually locally aggressive and require complete removal, including the surrounding apparently healthy bone, to provide the best chance of cure. GCTs, as well as other lesions located in the clivus, can nowadays be treated by a minimally invasive fully endoscopic extended endonasal approach. This approach ensures a more direct route to the craniovertebral junction than other possible approaches (transfacial, extended lateral, and posterolateral approaches). The case reported is a clival GCT operated on by an extended endonasal approach that provides another contribution on how to address one of the most feared complications attributed to this approach: a massive bleed due to an internal carotid artery injury.

Piezosurgery for osteotomies in orbital surgery: Our experience and review of the literature.

INTRODUCTION Piezoelectric bone surgery, simply known as Piezosurgery(®), is a new promising technique for bone cutting based on ultrasonic microvibrations that allows to perform precise and thin osteotomies with soft tissue sparing. PRESENTATION OF CASE A 45-years-old woman presenting with progressive left ocular pain, diplopia on the lateral left gaze, and visible exophthalmos was admitted to our department. CT scan and MRI images documented a left supero-lateral orbital lesion. A left lateral orbitotomy using the piezoelectric scalpel was performed. The tumour (lacrimal gland lymphoma) was completely removed with no injuries to the orbital structures and with a perfect realignment of the bone stumps. DISCUSSION High powered pneumatic osteotome are commonly used to perform craniotomies. Large bone cutting groove and high temperatures developing at the contact site could produce an uneasy bone healing. The use of a piezoelectric scalpel allows to realize precise and thin osteotomies, facilitating craniotomys borders ossification and avoiding injuries to non-osseous structures. CONCLUSION Widely used in Oral and Maxillofacial Surgery, Piezosurgery(®) can also be useful in neurosurgical approaches in order to obtain a faster bone flap re-ossification, a better aesthetic result, and a lower risks of dural layer and soft tissue damage.

Posterior Titanium Screw Fixation without Debridement of Infected Tissue for the Treatment of Thoracolumbar Spontaneous Pyogenic Spondylodiscitis

Study Design Retrospective study. Purpose The aim of our study was to analyze the safety and effectiveness of posterior pedicle screw fixation for treatment of pyogenic spondylodiscitis (PSD) without formal debridement of the infected tissue. Overview of Literature Posterior titanium screw fixation without formal debridement of the infected tissue and anterior column reconstruction for the treatment of PSD is still controversial. Methods From March 2008 to June 2013, 18 patients with PSD underwent posterior titanium fixation with or without decompression, according to their neurological deficit. Postero-lateral fusion with allograft transplantation alone or bone graft with both the allogenic bone and the autologous bone was also performed. The outcome was assessed using the visual analogue scale (VAS) for pain and the Frankel grading system for neurological status. Normalization both of C-reactive protein (CRP) and erythrocyte sedimentation rate was adopted as criterion for discontinuation of antibiotic therapy and infection healing. Segmental instability and fusion were also analyzed. Results At the mean follow-up time of 30.16 months (range, 24–53 months), resolution of spinal infection was achieved in all patients. The mean CRP before surgery was 14.32±7.9 mg/dL, and at the final follow-up, the mean CRP decreased to 0.5±0.33 mg/dL (p <0.005). Follow-up computed tomography scan at 12 months after surgery revealed solid fusion in all patients. The VAS before surgery was 9.16±1.29 and at the final follow-up, it improved to 1.38±2.03, which was statistically significant (p <0.05). Eleven patients out of eighteen (61.11%) with initial neurological impairment had an average improvement of 1.27 grades at the final follow-up documented with the Frankel grading system. Conclusions Posterior screw fixation with titanium instrumentation was safe and effective in terms of stability and restoration of neurological impairment. Fixation also rapidly reduced back pain.

Neurological outcome in a series of 58 patients operated for traumatic thoracolumbar spinal cord injuries.

Background: Traumatic thoracolumbar spinal fractures represent approximately 65% of all traumatic spinal fractures and are frequently associated to permanent disability with significant social and economic impact. These injuries create severe physical limitations depending on neurological status, level of fracture, severity of injury, patient age and comorbidities. Predicting neurological improvement in patients with traumatic spinal cord injuries (SCIs) is very difficult because it is related to different preoperative prognostic factors. We evaluated the neurological improvement related to the preoperative neurological conditions and the anatomic level of spinal cord injury. Methods: From January 2004 to June 2010, we operated 207 patients for unstable thoracolumbar spinal fractures. We carried out a retrospective analysis of 69 patients with traumatic SCIs operated on by a posterior fixation performed within 24 hours from the trauma. The preoperative neurological conditions (ASIA grade), the type of the fracture, the anatomic level of spinal cord injury and the postoperative neurological improvement were evaluated for each patient. Results: The ASIA grade at admission (P = 0,0005), the fracture type according to the AO spine classification (P = 0,0002), and the anatomic location of the injury (P = 0,0213) represented predictive factors of neurological improvement at univariate analysis. The preoperative neurological status (P = 0,0491) and the fracture type (P = 0,049) confirmed a positive predictive value also in the multivariate analysis. Conclusions: Our study confirms that the preoperative neurological status, the fracture type and the anatomic location of the fracture are predictive factors of the neurological outcome in patients with spinal cord injury.

Piezosurgery as a further technical adjunct in minimally invasive supraorbital keyhole approach and lateral orbitotomy.

OBJECTIVE One of the problems in neurosurgery is how to perform rapid and effective craniotomies that minimize the risk of injury to underlying eloquent structures. The traditional high-powered pneumatic tools and saws are efficient in terms of speed and penetration, but they can provoke bone necrosis and sometimes damage neurovascular structures. As an alternative, we evaluated the piezoelectric bone scalpel (piezosurgery), a device that potentially allows thinner and more precise bone cutting without lesioning neighboring delicate structures, even in the case of accidental contact. MATERIAL AND METHODS From January 2009 to December 2011, 20 patients (8 men and 12 women), 19 to 72 years of age (mean: 49.3 years) were treated using piezosurgery. Surgery was performed for the removal of anterior cranial fossa meningiomas, orbital tumors, and sinonasal lesions with intracranial extension. RESULTS The time required to perform craniotomy using piezosurgery is a few minutes longer than with traditional drills. No damage was observed using the piezoelectric device. Follow-up clinical and neuroradiologic evaluation showed a faster and better ossification of the bone flap with good esthetic results. CONCLUSIONS Piezosurgery is a new promising technique for selective bone cutting with soft tissue preservation. This instrument seems suitable to perform precise thin osteotomies while limiting damage to the bone itself and to the underlying delicate structures even in the case of unintentional contact. These advantages make the piezoelectric bone scalpel a particularly attractive instrument in neurosurgery.

Minimally Invasive Supraorbital Key-hole Approach for the Treatment of Anterior Cranial Fossa Meningiomas

The most important target of minimally invasive surgery is to obtain the best therapeutic effect with the least iatrogenic injury. In this background, a pivotal role in contemporary neurosurgery is played by the supraorbital key-hole approach proposed by Perneczky for anterior cranial base surgery. In this article, it is presented as a possible valid alternative to the traditional craniotomies in anterior cranial fossa meningiomas removal. From January 2008 to January 2012 at our department 56 patients underwent anterior cranial base meningiomas removal. Thirty-three patients were submitted to traditional approaches while 23 to supraorbital key-hole technique. A clinical and neuroradiological pre- and postoperative evaluation were performed, with attention to eventual complications, length of surgical procedure, and hospitalization. Compared to traditional approaches the supraorbital key-hole approach was associated neither to a greater range of postoperative complications nor to a longer surgical procedure and hospitalization while permitting the same lesion control. With this technique, minimization of brain exposition and manipulation with reduction of unwanted iatrogenic injuries, neurovascular structures preservation, and a better aesthetic result are possible. The supraorbital key-hole approach according to Perneckzy could represent a valid alternative to traditional approaches in anterior cranial base meningiomas surgery.

Surgical treatment of cervical spine trauma: Our experience and results.

Objective and Background: The objective of this study is to evaluate how the neurological outcome in patients operated for cervical spinal cord injury (SCI) is influenced by surgical timing, admission American Spinal Injury Association (ASIA) grading system, and age. Materials and Methods: From January 2004 to December 2011, we operated 110 patients with cervical SCI. Fifty-seven of them (44 males and 13 females) with preoperative neurological deficit, were included in this study with a complete follow-up. Age, sex, associated comorbidities (evaluated with Charlson comorbidity index [CCI]), mechanism of trauma, preoperative and follow-up ASIA score, time elapsed from injury to surgical treatment, preoperative cervical computed tomography scan or magnetic resonance imaging, type of fractures, and surgical procedure were evaluated for each patient. The patient population was divided into two groups related to the timing of surgery: Ultra-early surgery group (within 12 h from the trauma, 27 patients) and early surgery (within 12–72 h from the trauma, 30 patients). Statistical Analysis Used: The univariate analysis of data was carried out by the Chi-square test for discrete variables, the t-test for the continuous ones. Logistic regression was used for the multivariate analysis. Results: Neurological outcome was statistically better in ultra-early surgery group (<12 h) than in patient underwent surgery within 12–72 h (82.14% vs. 31%, multivariate analysis P = 0.005). The neurological improvement was also correlated with the age and the ASIA grade at admission in the univariate analysis (P = 0.006 and P = 0.017 respectively) and in the multivariate 1 (P = 0.037 and P = 0.006 respectively) while the CCI was correlated with the improvement only in the univariate analysis (P = 0.007). Conclusion: Nowadays, in patients with cervical SCI early surgery could be associated with improved outcome, most in case of young people with mild neurological impairment.

A rare case of chordoma and craniopharyngioma treated by an endoscopic endonasal, transtubercular transclival approach.

Co-occurrence of different brain tumors is rarely observed, being more frequent in patients affected by genetic syndromes like phacomatoses. Different histological types of intracranial lesions may present at different times in the clinical history of the patient or, more rarely, they may occurr at the same moment. In these last cases, particularly for tumors located in adjacent areas of the brain, diagnostic difficulties may arise. Moreover, even when the correct diagnosis is established, treatment strategy becomes complex and a single staged approach could be ineffective in obtaining successful tumor removal. We report a case of simultaneous sellar-suprasellar craniopharyngioma and intradural clival chordoma, successfully treated by a single staged, extended, fully endoscopic endonasal approach, which required no following adjuvant therapy. We also discuss the potential etiopathogenesis of the two lesions, reviewing the literature.

Shape modifications of porous hydroxyapatite prostheses to improve rigid implant fixation: Experience in 12 cases

Background: Various methods of fixation have been described for custom made hydroxyapatite cranial implants. Their poor malleability limits most of the common used fixation techniques because of the high risk of cranioplastys fracturing or higher exposure to infections. We present our experience with a new fixation technique, based on an appositely premodified hydroxyapatite implants. Methods: In a 2-year time period, 12 patients underwent cranioplasty by a modified custom made porous hydroxyapatite implant. Once the three-dimensional computer model of the prostheses was performed, three semicircular extensions placed at strategic positions were drawn and the final prosthesis was realized. At surgery, holes fitting the extensions were drilled into the skull borders and the implant was easily embedded inside the defect. Small titanium meshes overlying the extensions were fixed by screws to the surrounding bone. Results: A minimal increase of operative times was recorded, with drilling and fixation requiring additional 30 and 15 minutes, respectively. Optimal contact between cranioplasty and skull borders was always observed at control computed tomography (CT) scans. Permanent rigid fixation was obtained in all cases, with good functional and aesthetic results at follow-up. Conclusions: Modifications of hydroxyapatite implants are obtained without additional costs. The minimal increase of operative times is largely counterbalanced by optimal fixation results. Finally, the bone drilling and the immediate proximity of bone to prosthesis might enhance the potential for osteogenesis and osteointegration.